Curettage and electrocoagulation versus surgical excision in the treatment of low-risk basal cell carcinoma – Postoperative follow-up and satisfaction at three months: randomized clinical trial

urettage and electrocoagulation ersus surgical excision in the reatment of low-risk basal cell carcinoma Postoperative follow-up and satisfaction t three months: randomized clinical trial feet), or low-risk regions on the face (forehead and cheek), with a pattern of nodular or superficial expansive growth.2 The lesions were outlined with a surgical pen, with a safety margin of 3 mm with the aid of a dermatoscope. In the C&E group, the central portion of the lesion was excised with a tangential surgical blade incision (shaving) and sent for anatomopathological examination. The remainder of the tumor tissue was curetted until complete elimination on inspection, in addition to the surrounding skin up to a previous demarcation of three millimeters, or to the limit of friable tissue. Subsequently, the floor of the curetted area was electrocoagulated. The C&E process was repeated for a total of two cycles.4,5 In the surgical excision group, the lesion was removed using a spindle-shaped incision, following the skin tension lines, guided by the demarcation of the three-mm safety margin, closed with direct sutures, using mononylon 4.0 (trunk and limbs) and 5.0 (face) using simple interrupted stitches.6 The patients were instructed to maintain local wound care by cleaning and dressing the wound with antibiotic ointment and to have the stitches removed, in the case of conventional surgery, at the basic health unit. The studied characteristics were: sex; age; years of schooling; smoking status; phototype; clinical type of BCC; lesion diameter; signs of tumor recurrence; postoperative infection requiring local or systemic care; suture dehiscence; significant bleeding requiring health care; clinically evident scar retraction; pain intensity according to the analog scale from 1 to 10; pruritus according to the analogous scale from 1 to 10; the impact of postoperative care on the daily routine using a Likert-type question with the options almost never, a few times, many times, almost always; satisfaction with the surgical procedure using a Likert-type question with the options: none, a little, moderate, a lot and total; and aesthetic scar result at three months using the Patient and Observer Scar Assessment Scale and an analog scale, ranging from 0 to 10.7 The sample size calculation resulted in 98 lesions and was based on a difference in maximal satisfaction rate with the expected procedure of 60% versus 85% for a power test of 80% and p ≤ 0.05, two-tailed. The characteristics with p < 0.2 in the bivariate analyses were analyzed by multivariate mixed models adjusted f ear Editor,

feet), or low-risk regions on the face (forehead and cheek), with a pattern of nodular or superficial expansive growth. 2 The lesions were outlined with a surgical pen, with a safety margin of 3 mm with the aid of a dermatoscope.
In the C&E group, the central portion of the lesion was excised with a tangential surgical blade incision (shaving) and sent for anatomopathological examination. The remainder of the tumor tissue was curetted until complete elimination on inspection, in addition to the surrounding skin up to a previous demarcation of three millimeters, or to the limit of friable tissue. Subsequently, the floor of the curetted area was electrocoagulated. The C&E process was repeated for a total of two cycles. 4,5 In the surgical excision group, the lesion was removed using a spindle-shaped incision, following the skin tension lines, guided by the demarcation of the three-mm safety margin, closed with direct sutures, using mononylon 4.0 (trunk and limbs) and 5.0 (face) using simple interrupted stitches. 6 The patients were instructed to maintain local wound care by cleaning and dressing the wound with antibiotic ointment and to have the stitches removed, in the case of conventional surgery, at the basic health unit.
The studied characteristics were: sex; age; years of schooling; smoking status; phototype; clinical type of BCC; lesion diameter; signs of tumor recurrence; postoperative infection requiring local or systemic care; suture dehiscence; significant bleeding requiring health care; clinically evident scar retraction; pain intensity according to the analog scale from 1 to 10; pruritus according to the analogous scale from 1 to 10; the impact of postoperative care on the daily routine using a Likert-type question with the options almost never, a few times, many times, almost always; satisfaction with the surgical procedure using a Likert-type question with the options: none, a little, moderate, a lot and total; and aesthetic scar result at three months using the Patient and Observer Scar Assessment Scale and an analog scale, ranging from 0 to 10. 7 The sample size calculation resulted in 98 lesions and was based on a difference in maximal satisfaction rate with the expected procedure of 60% versus 85% for a power test of 80% and p ≤ 0.05, two-tailed.
The characteristics with p < 0.2 in the bivariate analyses were analyzed by multivariate mixed models adjusted for age, sex, phototype, years of schooling, smoking status, size and location of lesions, with the intervention used as the dependent variable. Two-tailed values of p ≤ 0.05 were considered significant.
A total of 116 lessons from 82 patients were included, 49% of which were female, with a mean of 1.4 lesions per patient (Table 1).    All lesions had the diagnosis of basal cell carcinoma confirmed on anatomopathological examination, and there were no clinical and dermoscopic signs of local recurrence or residual tumor at three months of follow-up. Table 2 shows the characteristics of the lesions in terms of postoperative follow up, where there are no significant differences in the bivariate analyses. The characteristics with p < 0.2 were analyzed by multivariate mixed models adjusted for age, sex, phototype, years of schooling, smoking status, size, and location of the lesions. The variables pigmentation (p = 0.02), color change (p < 0.01), stiffness (p < 0.01), thickness (p = 0.02) and the patient total POSAS score (p = 0.01) were significantly associated with the surgical technique, showing worse scores for C&E.
Few studies have evaluated the degree of satisfaction or quality of life of patients with different treatments. A study carried out in 2007 evaluated the impact of different techniques on the patient quality of life through the 16item Skindex one and two years after the procedure, finding worse results for C&E when compared to the conventional excision and Mohs surgery. It is important to emphasize that the lesions were not restricted in size or risk level, having a mean diameter of 9.9 mm. 8 In the present study, the evaluation carried out three months after the procedure did not identify significant differences regarding the satisfaction with the treatment, as well as greater difficulties in local care, symptoms, or surgical complications, despite slight but significant differences regarding the scar aspect. It is believed that such observations may change over time, with the reassessment of these patients being relevant, as some scar aspects tend to improve over time, especially in the elderly. 9,10 The present study has limitations related to the singlecenter, non-blinded study design, and evaluation limited to three months. However, the results were controlled for clinical and demographic characteristics regarding satisfaction outcomes, complications, and scar aspect, indicating satisfactory results for C&E when compared to conventional surgery for the profile of the studied lesions.

Financial support
None declared.

Authors' contributions
Luan Moura Hortencio Bastos: Design of the study; collection of data; interpretation of data; drafting of the manuscript; approval of the final version of the manuscript.
Larissa Pierri Carvalho: Data collection; data interpretation; critical review of important intellectual content; approval of the final version of the manuscript.
Gabriela Roncada Haddad: Data collection; data interpretation; critical review of important intellectual content; approval of the final version of the manuscript.
Anna Carolina Miola: Data collection; data interpretation; critical review of important intellectual content; approval of the final version of the manuscript.
Juliano Vilaverde Schmitt: Design and planning of the study, data collection, or analysis and interpretation of data; critical review of important intellectual content, approval of the final version of the manuscript.